Provider Demographics
NPI:1841781002
Name:GRAY, RANDI KENNEDY (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDI
Middle Name:KENNEDY
Last Name:GRAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:RANDI
Other - Middle Name:KENNEDY
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:504 E CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-4842
Mailing Address - Country:US
Mailing Address - Phone:918-774-4369
Mailing Address - Fax:918-776-0835
Practice Address - Street 1:504 E CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955
Practice Address - Country:US
Practice Address - Phone:918-774-4369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK70561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR$$$$$$$$$Medicaid